The nurse caring for the client diagnosed with sickle cell crisis places priority on which specific goal(s) prior to discharge? (SELECT ALL THAT APPLY)

Decrease fluid intake of 1000 mL/day to prevent fluid overload

The client verbalizes the procedure for a 24-hour urine collection

Oxygenation and perfusion to meet cellular and metabolic needs

Complications are prevented or minimized

Pain is relieved or controlled

Answer and Explanation

Correct Answer : C,D,E

A. Decrease fluid intake of 1000 mL/day to prevent fluid overload: This goal is not appropriate. Clients with sickle cell crisis often require increased fluid intake to prevent dehydration and promote circulation, so limiting fluids is counterproductive.

B. The client verbalizes the procedure for a 24-hour urine collection: While understanding this procedure may be relevant for monitoring kidney function or hydration status, it is not a priority goal directly related to managing sickle cell crisis.
C. Oxygenation and perfusion to meet cellular and metabolic needs: Ensuring adequate oxygenation and perfusion is crucial in managing sickle cell crisis, as compromised blood flow can exacerbate pain and lead to further complications.

D. Complications are prevented or minimized: Preventing complications, such as infections or acute chest syndrome, is a key goal in managing a client with sickle cell disease, making this a critical aspect of discharge planning.

E. Pain is relieved or controlled: Pain management is a primary focus during a sickle cell crisis. Ensuring that pain is effectively managed before discharge is essential for the client's comfort and overall well-being.

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Correct Answer is B

Explanation

A. Increase calcium in the diet: While calcium is important, it's not the most critical aspect in managing hypertension compared to weight management.

B. Monitor weight on a weekly basis: Weight management is crucial for clients with hypertension, as fluctuations can indicate changes in fluid retention or overall health. Regular monitoring can help in managing blood pressure.

C. Obtain blood pressure checks twice a year: This is insufficient for monitoring hypertension; more frequent checks are generally recommended.

D. Have yearly eye examinations: While important for overall health, it’s not as directly related to the management of hypertension as monitoring weight.

A. Increased platelet count B. Elevated troponins C. Decreased homocysteine levels D. Elevated CK-MB E. Decreased alkaline phosphatase (ALT)

Correct Answer is B

Explanation

A. Increased platelet count: While platelet activation can occur in unstable angina, an increased platelet count alone does not indicate heart damage. It is more relevant to thrombotic events than direct myocardial injury.

B. Elevated troponins: Troponin is a protein released when the heart muscle is damaged. Elevated levels are a key indicator of myocardial injury, making this a significant finding in the context of unstable angina.

C. Decreased homocysteine levels: Homocysteine levels are related to cardiovascular risk but are not directly indicative of heart damage. Elevated levels may suggest risk but do not confirm damage.

D. Elevated CK-MB: Creatine kinase-MB is an enzyme found in heart muscle. Elevated levels are indicative of myocardial injury, making this a relevant laboratory test for assessing heart damage in unstable angina.

E. Decreased alkaline phosphatase (ALT): Alkaline phosphatase is primarily related to liver and bone health and does not indicate heart damage. Decreased levels of ALT (alanine aminotransferase) are not relevant to myocardial injury.

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The nurse caring for the client diagnosed with sickle cell crisis places priority on which specific goal(s) prior to discharge? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The nurse who is providing instructions to a client with hypertension will stress that it is most important to:

Correct Answer is B

Explanation

The nurse is reviewing the chart of a client with a diagnosis of unstable angina. Which laboratory test(s) result(s) should the nurse recognize as an Indication of heart damage? (SELECT ALL THAT APPLY)

Correct Answer is B

Explanation

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